Survey

DATE OF FLIGHT(DD/MM/YYYY)

FLIGHT NUMBER

PERSONAL DATA

NAME

SURNAME

AGE

DATE OF BIRTH (DD/MM/YYYY)

PLACE OF BIRTH

NATIONALITY

REFERENCE ACCOMPANYING PERSON

NAME

SURNAME

DATE OF BIRTH (DD/MM/YYYY)

PLACE OF BIRTH

NATIONALITY

ROLE (PARENT, EDUCATOR, ETC.)

TELEPHONE

FUNCTIONING

1) MAIN MEANS OF COMMUNICATIVE EXPRESSION

Gestuale (SPECIFY)
VISUAL (AUGMENTATIVE COMMUNICATION)
VERBAL
OTHER (SPECIFY)

2) HOW DO YOU JUDGE THE COMMUNICATION CHANNEL USED BY THE CHILD TO COMMUNICATE HIS/HER OWN NEEDS?

HE/SHE IS NOT ABLE TO COMMUNICATE HIS/HER PRIMARY NEEDS (E.G. HUNGER, THIRST, NEED TO GO TO THE BATHROOM)

HE/SHE ONLY MANAGES TO COMMUNICATE PRIMARY NEEDS IN SPECIFIC SITUATIONS OR WITH SPECIFIC PEOPLE

HE/SHE MANAGES TO COMMUNICATE PRIMARY NEEDS REGARDLESS OF THE SITUATION OR PERSONS

HE/SHE IS ONLY ABLE TO COMMUNICATE PRIMARY NEEDS AND EXPLAIN THEIR ORIGIN IN SPECIFIC SITUATIONS OR WITH SPECIFIC PEOPLE

HE/SHE MANAGES TO COMMUNICATE PRIMARY NEEDS AND EXPLAIN THEIR ORIGIN REGARDLESS OF THE SITUATION OR PERSONS

SENSORIAL ASPECT

3) WHICH OF THE FOLLOWING STIMULATIONS IS ANNOYING?

BEHAVIOURAL ASPECT

IN CASE OF FRUSTRATION OR INTOLERANCE, WHAT IS THE MOST AGGRESSIVE BEHAVIOUR THAT COULD BE MANIFESTED?

AGGRESSION DIRECTED AGAINST OTHERS

SELF-AGGRESSION

DESTRUCTION OF THE ENVIRONMENT

INDICATE OTHER BEHAVIOUR THAT COULD MANIFEST IN CASE OF FRUSTRATION OR INTOLERANCE

5) INDICATE OTHER BEHAVIOUR THAT COULD MANIFEST IN CASE OF FRUSTRATION OR INTOLERANCE

MOTOR AGITATION (E.G. RUNS, ESCAPES, AVOIDS TASK) (SPECIFY)
SCREAMS
MOTOR STEREOTYPE (SPECIFY)
ECHOLALIA (SPECIFY)
CRIES
WITHDRAWS (HIDES OR RUNS AWAY)
OTHER (SPECIFY)

7) CONSIDERING THE MOST AGGRESSIVE BEHAVIOUR MANIFESTS, HOW LONG DO THE ACTIVITIES, OBJECTS OR ENVIRONMENTS LISTED ABOVE TAKE TO CALM THE CHILD DOWN?

LESS THAN A MINUTE

FROM 1 TO 10 MINUTES

FROM 10 TO 30 MINUTES

FROM 30 TO 60 MINUTES

MORE THAN 60 MINUTES

9) DOES HE/SHE HAVE ANY FOOD INTOLERANCES?

IF YES, SPECIFY WHICH

10) IS HE/SHE PICKY ABOUT FOOD?

IF YES, INDICATE THE FOODS AND DRINK CONSUMED

11) INDICATE ANY SPECIAL REQUESTS COMPARED TO THE FOOD ON THE FLIGHT

PREVIOUS FLIGHT EXPERIENCE

12) HAS HE/SHE BEEN ON ANY FLIGHTS PREVIOUSLY?

13) HOW OLD WAS HE/SHE ON LAST FLIGHT EXPERIENCE?

14) WERE THERE ANY COMPLICATIONS DURING THE SECURITY CONTROLS, THE WAIT OR DURING THE FLIGHT?

SEND TO ME

EMAIL TO NOTIFY

MUSIC	MUSIC Yes No I DON'T KNOW
LOUD NOISES	LOUD NOISES Yes No I DON'T KNOW
SUDDEN NOISES	SUDDEN NOISES Yes No I DON'T KNOW
PERSISTENT NOISES	PERSISTENT NOISES Yes No I DON'T KNOW
BRIGHT COLOURS	BRIGHT COLOURS Yes No I DON'T KNOW
REFLECTING SURFACES	REFLECTING SURFACES Yes No I DON'T KNOW
SUNLIGHT	SUNLIGHT Yes No I DON'T KNOW
COLOURED LIGHTS	COLOURED LIGHTS Yes No I DON'T KNOW
THE DARK	THE DARK Yes No I DON'T KNOW
VISUAL ELEMENTS (IMAGES/VIDEOS)	VISUAL ELEMENTS (IMAGES/VIDEOS) Yes No I DON'T KNOW
VIBRATION	VIBRATION Yes No I DON'T KNOW
HEAT	HEAT Yes No I DON'T KNOW
COLD	COLD Yes No I DON'T KNOW
BEING ALONE IN CERTAIN PLACES	BEING ALONE IN CERTAIN PLACES Yes No I DON'T KNOW
LARGE ENVIRONMENTS OR OPEN SPACE	LARGE ENVIRONMENTS OR OPEN SPACE Yes No I DON'T KNOW
LONG CORRIDORS	LONG CORRIDORS Yes No I DON'T KNOW
CROWDED PLACES	CROWDED PLACES Yes No I DON'T KNOW
INTERACTION WITH OTHER PEOPLE	INTERACTION WITH OTHER PEOPLE Yes No I DON'T KNOW
PHYSICAL CONTACT WITH OTHER PEOPLE	PHYSICAL CONTACT WITH OTHER PEOPLE Yes No I DON'T KNOW
SLIDING DOORS	SLIDING DOORS Yes No I DON'T KNOW

WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED?	WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED? HE/SHE MANIFESTS THE INTENTION TO GRAB HE/SHE MANIFESTS THE INTENTION TO HIT GRABS THE OTHER PERSON HITS WITHOUT LEAVING MARKS HITS AND LEAVES MARKS
HOW FREQUENT ARE THESE EPISODES?	HOW FREQUENT ARE THESE EPISODES? HARDLY EVER (LESS THAN ONCE A MONTH) RARELY (1-2 TIMES A MONTH) SOMETIMES (ONCE A WEEK) OFTEN (2-3 TIMES A WEEK) MOLTO SPESSO (PIÙ DI 3 VOLTE ALLA SETTIMANA)
HOW LONG DO THESE EPISODES USUALLY LAST?	HOW LONG DO THESE EPISODES USUALLY LAST? LESS THAN A MINUTE FROM 1 TO 10 MINUTES FROM 10 TO 30 MINUTES FROM 30 TO 60 MINUTES MORE THAN 60 MINUTES

WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED?	WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED? HE/SHE MANIFESTS THE INTENTION TO HIT HIM/HERSELF AUTOSTIMULATION (E.G. PINCHES, SLAPS) CAUSES BRUISES OR ABRASIONS CAUSES TISSUE DAMAGE (E.G. HAIR OR CUTS) CAUSES FRACTURES OR FUNCTIONAL INJURIES
HOW FREQUENT ARE THESE EPISODES?	HOW FREQUENT ARE THESE EPISODES? HARDLY EVER (LESS THAN ONCE A MONTH) RARELY (1-2 TIMES A MONTH) SOMETIMES (ONCE A WEEK) OFTEN (2-3 TIMES A WEEK) MOLTO SPESSO (PIÙ DI 3 VOLTE ALLA SETTIMANA)
HOW LONG DO THESE EPISODES USUALLY LAST?	HOW LONG DO THESE EPISODES USUALLY LAST? LESS THAN A MINUTE FROM 1 TO 10 MINUTES FROM 10 TO 30 MINUTES FROM 30 TO 60 MINUTES MORE THAN 60 MINUTES

WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED?	WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED? SHOWS THE INTENTION TO THROW OR BREAK THINGS DISTRUGGE LIEVEMENTE OGGETTI A PORTATA DI MANO, SENZA COMPROMETTERNE LA FUNZIONE DISTRUGGE GRAVEMENTE OGGETTI A PORTATA DI MANO SENZA, COMPROMETTENDONE LA FUNZIONE DISTRUGGE LIEVEMENTE OGGETTI FUORI DALLA PORTATA DI MANO DISTRUGGE GRAVEMENTE TUTTI O BUONA PARTE DEGLI OGGETTI PRESENTI NELL’AMBIENTE
HOW FREQUENT ARE THESE EPISODES?	HOW FREQUENT ARE THESE EPISODES? HARDLY EVER (LESS THAN ONCE A MONTH) RARELY (1-2 TIMES A MONTH) SOMETIMES (ONCE A WEEK) OFTEN (2-3 TIMES A WEEK) MOLTO SPESSO (PIÙ DI 3 VOLTE ALLA SETTIMANA)
HOW LONG DO THESE EPISODES USUALLY LAST?	HOW LONG DO THESE EPISODES USUALLY LAST? LESS THAN A MINUTE FROM 1 TO 10 MINUTES FROM 10 TO 30 MINUTES FROM 30 TO 60 MINUTES MORE THAN 60 MINUTES

THE FIELDS MARKED WITH AN * ARE COMPULSORY